European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> When Zoster Virus Hides a Primary Brain Lymphoma <p><em>Aim:</em> To describe an unusual presentation of a primary lymphoma of the central nervous system in a patient who, four months prior to admission, was diagnosed with herpes zoster ophthalmicus (HZO). <br> <em>Case description:</em> A 68-year-old man, with a history of HZO, was admitted to the emergency department with nausea and vomiting that had persisted over the previous two weeks. Neurological evaluation showed right ptosis, divergent strabismus and anisocoria. Blood tests showed high c-reactive protein, while serology was negative for human immunodeficiency virus. A brain CT scan revealed three round lesions, slightly hyperdense, periventricular in the occipital and frontal regions, which biopsy revealed to be a diffuse large B-cell lymphoma. The patient started chemotherapy but progression to death was inevitable.<br> <em>Conclusion:</em> The authors describe an unusual presentation of primary lymphoma of the central nervous system and urge physicians to be aware of this presentation in order to avoid misdiagnosis.</p> Rafael Ferreira Nascimento João Miguel Freitas Maria da Luz Brazão ##submission.copyrightStatement## 2019-12-05 2019-12-05 10.12890/2019_001341 Two Dabigatran Fast Reversals in a 4-month Period – a Case Report <p><em>Introduction:</em> Idarucizumab is available for immediate reversal of dabigatran-induced anticoagulation in life-threatening bleeding or urgent surgery in patients with non-valvular atrial fibrillation (nvAF).<br> <em>Case description:</em> We report a case of an 85-year-old female treated with dabigatran for nvAF, submitted to two fast reversal procedures with idarucizumab in a 4-month period. In the first emergency episode, the patient was admitted due to a fall-related cerebral haemorrhage and subdural haematoma. There was a fast reversal of the effects of dabigatran after idarucizumab administration, which allowed stoppage of the bleeding and a decrease in intracranial pressure, with full patient recovery. Four months later, the patient revisited the hospital complaining of diffuse abdominal pain while on the same antithrombotic therapy. Physical examination showed signs of peritoneal irritation and the use of idarucizumab to reverse the effects of dabigatran was decided upon to secure normal bleeding conditions before surgery.<br> <em>Discussion:</em> Idarucizumab is an efficient, safe and feasible option for dabigatran-treated nvAF patients, when urgent anticoagulant effect reversal is needed.</p> Vítor Fagundes Mari Mesquita ##submission.copyrightStatement## 2019-12-04 2019-12-04 10.12890/2019_001311 Cervical Lymphadenopathy in a Nonagenarian Woman: What to Think? <p>Tuberculosis remains a worldwide public health problem. Cervical tuberculous lymphadenitis (TBL) or scrofula is the most common form of extrapulmonary tuberculosis, affecting the cervical lymph nodes. We report the case of a 93-year-old woman presenting with cervical adenopathies with 3 months duration. Fine needle aspiration (FNA) biopsy yielded a noncaseous granulomatous process, but was negative for Mycobacterium tuberculosis (MT). As the adenopathies had grown, an excisional biopsy was performed. An extensive study of infectious aetiologies was performed, including for MT, with a negative outcome. Owing to the persistence of cervical lymphadenitis with caseous granulomas, a diagnosis of TBL was strongly suspected and presumptive treatment was initiated. Afterwards, diagnostic confirmation was obtained by isolation of MT in the lymph node culture. The patient presented a favourable clinical outcome. This case highlights that a high index of suspicion is essential for the diagnosis of TBL, especially in the elderly, and emphasizes the importance of pursuing diagnostic confirmation, in which FNA and excisional biopsy plays a key role.</p> Vanessa Meireles Chaves Fernando Nogueira Gilberto Pires da Rosa Sofia Tavares Inês Ferreira Ana Oliveira Monteiro Ester Ferreira ##submission.copyrightStatement## 2019-12-03 2019-12-03 10.12890/2019_001336 Moyamoya Syndrome after Radiation Therapy: a Clinical Report <p>Moyamoya syndrome (MMS) is a rare, chronic and progressive vasculopathy with a characteristic angiographic pattern and well-recognized predisposing conditions, such as cranial therapeutic radiation. We report the case of a 36-year-old Caucasian female with a history of craniopharyngioma treated with whole-brain radiotherapy 20 years previously. She was admitted to the emergency department with disorientation and imperceptible speech lasting for 1 hour. Upon examination, she had slight motor aphasia, without sensory or motor deficits. However, the neurological deficits worsened on standing position. The computed tomography (CT) angiogram and transcranial Doppler ultrasonography revealed occlusion of the distal portion of the left internal carotid artery (ICA). Mechanical thrombectomy was attempted without success. Head CT was repeated, revealing left periventricular acute ischaemic stroke. The cerebral angiography showed total occlusion of the left ICA with an exuberant network of transdural collateral vessels, confirming MMS. The patient completed a functional rehabilitation program with progressive improvement of deficits and maintained a multidisciplinary follow-up. MMS is a serious late complication from cranial radiation therapy and a well-described risk factor for ischaemic stroke in younger patients. Therefore, early detection and prompt treatment are mandatory, as the consequences can be disastrous, such as cognitive and neurologic decline due to repeated strokes.</p> Paulo Almeida Ana Rocha Gonçalo Alves Tiago Parreira Maria Silva António Cerejo Pedro Abreu Ana Monteiro ##submission.copyrightStatement## 2019-12-02 2019-12-02 10.12890/2019_001337 Haemoglobin A1C Levels Constantly Below Lower Reference Limit in a Diabetic Patient With Microcytic Anaemia <p><em>Introduction:</em> Haemoglobin A<sub>1C</sub> (A1C), as a parameter of long-term glycaemic control, has been adopted to guide diabetic therapy all over the world. However, falsely high or low A<sub>1C</sub> could be troublesome in daily practice. <br> <em>Case description:</em> A 75-year-old male diabetic patient affected by a reasonably inferred life-long history of microcytic anaemia was found to have abnormally low A<sub>1C</sub> values in the previous 5 months. Subsequent laboratory assessment with brilliant cresyl blue staining and haemoglobin electrophoresis detected haemoglobin H disease as the underlying cause of both the microcytic anaemia and the disturbed A<sub>1C</sub> measurement. <br> <em>Discussion:</em> Enhanced erythrocyte destruction such as in haemoglobin H disease could explain a falsely decreased A<sub>1C</sub> level very well. Upon facing a questionable A<sub>1C</sub> value, physicians dealing with diabetes should consider the possibility of undiscovered underlying causes rather than too tightly glycaemic control.</p> Frank Sheng Fan Chih-Hao Chen Hui-Chun Yang ##submission.copyrightStatement## 2019-11-29 2019-11-29 10.12890/2019_001338 Cardiac Amyloidosis Associated with Apolipoprotein A-IV Deposition Diagnosed by Mass Spectrometry-Based Proteomic Analysis <p>Amyloidosis is a group of disorders characterised by the accumulation of extracellular deposits of insoluble protein aggregates. Clinical management depends on the accurate identification of the amyloid precursor and underlying cause. We describe a rare case of apolipoprotein A-IV cardiac amyloidosis, the diagnosis of which required mass spectrometry-based proteomic analysis.</p> Elisabete Martins Joana Urbano Sérgio Leite Adriana Pinto Raquel Garcia Rui Bergantim Pedro Rodrigues Pereira Paulo Pinho Costa Hugo Osório Isabel Tavares ##submission.copyrightStatement## 2019-11-27 2019-11-27 10.12890/2019_001237 Catastrophic Gastrointestinal Bleeding: Always Consider Meckel’s Diverticulum <p>Meckel’s diverticulum, a congenital malformation of the gastrointestinal tract, is asymptomatic in the majority of patients but can be associated with some complications. Gastrointestinal bleeding is one such complication and is more common in children than in adults. Despite the variety of examinations available, diagnosis can be difficult, especially in older patients, because the sensitivity of examinations decreases with patient age. Here we present the case of a young man with gastrointestinal bleeding in whom a diagnosis of Meckel’s diverticulum was made intra-operatively.</p> Filipa Pedro Joana Romano Marta Rebelo Rogério Matias Eduarda Carmo ##submission.copyrightStatement## 2019-11-25 2019-11-25 10.12890/2019_001224 A Case of Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging of Eosinophilic Granulomatosis With Polyangiitis Combined With Non-tuberculous Mycobacterium <p>Fluorine-18-fluorodeoxyglucose positron emission tomography/ computed tomography (18FDG-PET/CT) has been used to diagnose vasculitis, tuberculosis and malignancy. Because PET/CT scan show hotspots during an activation of clinically suspected lesions, it is widely used for diagnosis. However, there are rare cases of PET/CT images for vasculitis combined with tuberculosis. Here we report a case of an eosinophilic granulomatosis with polyangiitis in a patient with disseminated non-tuberculosis mycobacterial infection in multiple sites mimicking metastatic malignacy and describe the associated PET/CT scan findings before and after treatment.</p> Juhyung Kim Man-Hoon Han Sang Jin Lee ##submission.copyrightStatement## 2019-11-22 2019-11-22 10.12890/2019_001299 Pituitary Apoplexy Following Systemic Anticoagulation <p>Pituitary apoplexy is a rare medico-surgical emergency that stems from an acute expansion of a pituitary adenoma from infarction or haemorrhage and where the treatment strategy is still controversial. Clinical presentation is highly variable and a high index of suspicion is needed to make the diagnosis. Furthermore, in less than half of cases, a precipitating event is identified. We report a case of a 74-year-old female who, after introduction of anticoagulation for pulmonary thromboembolism, presented with pituitary apoplexy heralded by acute adrenal insufficiency, headaches, visual symptoms and hypogonadotropic hypogonadism. Timely initiation of corticosteroids was crucial, and after stabilisation, a conservative treatment strategy was favoured with good long-term prognosis. Long-term follow-up of pituitary function also revealed new growth hormone deficiency.</p> Ana Rita Mairos dos Santos Carlos Tavares Bello Alice Sousa João Sequeira Duarte Luís Barreto Campos ##submission.copyrightStatement## 2019-11-20 2019-11-20 10.12890/2019_001254 The Reversed Halo Sign: Not Such a Specific Sign of Organising Pneumonia <p>The reversed halo sign is defined as a focal rounded area of ground-glass opacity surrounded by a more or less complete ring of consolidation. It is a relatively rare sign and initially considered a specific sign of organising pneumonia. We report the case of a 55-year-old female who was being followed-up in a pulmonology consultation due to a 6 mm nodule which required vigilance. On a re-evaluation chest CT scan, besides a stable 6 mm nodule, a 36 mm mass with the reversed halo sign was diagnosed. The presence of the reversed halo sign misled the multidisciplinary team into the diagnosis of organising pneumonia and initiation of corticotherapy was suggested. However, after further investigation, a final diagnosis of pulmonary tuberculosis was made. Even though this sign is relatively rare, and still considered an important clue to the diagnosis of organising pneumonia in immunocompetent patients, other causes must be excluded before starting treatment.</p> Inês Carrilho Oliveira Joana Carvalho Rita Rosa Catarina Barata ##submission.copyrightStatement## 2019-11-18 2019-11-18 10.12890/2019_001326